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This study examined whether environmental factors and practice characteristics influence the existence of patient-centered medical home elements in family practices in Virginia. The study used multiple secondary data sets to measure the external environment and a survey of family practices to enumerate and describe medical home elements and practice environment. Results show a positive association between organizational slack, organizational relationships, and stakeholder expectations on the existence of medical home elements. A negative association was found between competition and medical home elements. Medicare and managed care penetration were not associated with medical home elements. The ability or willingness, or both, of family practices to innovate along the patient-centered medical home model is constrained by important institutional and resource dependencies, and policy makers …